HESI RN
HESI RN Med Surg 3 Questions
Extract:
Question 1 of 5
A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1. The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?
Correct Answer: C
Rationale: The C8 and T1 spinal nerves control hand and finger movements. Testing grip strength assesses nerve integrity at the injury level.
Question 2 of 5
A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?
Correct Answer: C
Rationale: If the chest tube accidentally dislodges, an occlusive dressing (such as sterile gauze with petroleum jelly) should be applied immediately to prevent air from re-entering the pleural space, which could lead to a tension pneumothorax. Keeping sterile gauze at the bedside ensures rapid intervention in case of accidental chest tube removal.
Question 3 of 5
The nurse is caring for a client with massive gastrointestinal bleeding from a gastric ulcer who received 6 units packed red blood cells (PRBCs) and 2 units fresh frozen plasma (FFP). The most recent laboratory results are a hemoglobin of 8.0 g/dL (4.96 mmol/L), platelets of 82,000/gi bleeding, requiring urgent volume replacement to restore perfusion.
Correct Answer: A
Rationale: Administer a PRN bolus normal saline. The client is exhibiting signs of hypovolemic shock, including tachycardia (HR 110 bpm), tachypnea (RR 24), and hypotension (BP 80/50 mmHg) following massive gastrointestinal bleeding and multiple blood transfusions. Immediate fluid resuscitation with a normal saline bolus is the priority to restore intravascular volume, maintain perfusion, and prevent further deterioration.
Question 4 of 5
The nurse is completing a neurological assessment on a client with a head injury. The Glasgow Coma Scale (GCS) score is 14. Which intervention should the nurse implement?
Correct Answer: D
Rationale: A GSC of 14 indicates mild head injury. Frequent monitoring every 2 hours detects worsening conditions.
Question 5 of 5
A client admitted to the intensive care unit (ICU) with acute respiratory distress syndrome (ARDS) is intubated and placed on assist-control mechanical ventilation. When suctioning pulmonary secretions from the endotracheal tube (ETT) using a closed suction system, which action should the nurse implement to ensure that the client receives adequate oxygenation?
Correct Answer: B
Rationale: Pre-oxygenating by delivering additional breaths via the ventilator prevents hypoxia during suctioning, ensuring adequate oxygenation.